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. 2020 Sep 1;22(9):1328-1336.
doi: 10.1093/europace/euaa101.

Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients

Manuel Rattka  1 , Alexander Pott  1 , Anna Kühberger  1 , Karolina Weinmann  1 , Dominik Scharnbeck  1 , Tilman Stephan  1 , Michael Baumhardt  1 , Carlo Bothner  1 , Mario Iturbe Orbe  1 , Wolfgang Rottbauer  1 , Tillman Dahme  1
Affiliations

Restoration of sinus rhythm by pulmonary vein isolation improves heart failure with preserved ejection fraction in atrial fibrillation patients

Manuel Rattka et al. Europace. .

Abstract

Aims: Atrial fibrillation (AF) in patients suffering from heart failure with preserved ejection fraction (HFpEF) is associated with increased symptoms and higher morbidity and mortality. Effective treatment strategies for this patient population have not yet been established.

Methods and results: We analysed clinical outcomes and echocardiographic parameters of patients with AF and HFpEF who underwent pulmonary vein isolation (PVI). Out of 374 PVI patients, we identified 35 patients suffering from concomitant HFpEF. Freedom from atrial tachyarrhythmia (AT) after 1 year was 80%. Heart failure symptoms assessed by New York Heart Association class significantly improved from 2.7 ± 0.7 to 1.7 ± 0.9 (P < 0.001). We observed regression of diastolic dysfunction by echocardiography 12 months after the index procedure. Moreover, 15 patients (42.9%) experienced complete resolution of HFpEF after a single ablation procedure. Multivariate logistic regression revealed absence of AT recurrence as an independent predictor of recovery from HFpEF (hazard ratio 11.37, 95% confidence interval 1.70-75.84, P = 0.009). Furthermore, resolution of HFpEF by achieving freedom from AT recurrence by PVI, including multiple procedures, led to a significant reduction of hospitalizations.

Conclusion: Our results suggest that restoration of sinus rhythm by PVI in HFpEF patients with concomitant AF induces reverse remodelling, improvement of symptoms, resolution of HFpEF and subsequently decrease of hospitalizations. Randomized controlled trials are warranted to confirm our results.

Keywords: Ablation; Atrial fibrillation; Cryoballoon; Heart failure with preserved ejection fraction; Pulmonary vein isolation; Remodelling.

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Figures

Figure 1
Figure 1
Study flowchart. AF, atrial fibrillation; ECG, electrocardiogram; ESC, European Society of Cardiology; HFpEF, heart failure with preserved ejection fraction; LVEF, left ventricular ejection fraction; no HF, no heart failure; pts, patients; TTE, transthoracic echocardiography.
Figure 2
Figure 2
Kaplan–Meier curves for freedom from atrial tachyarrhythmia recurrence. HFpEF, heart failure with preserved ejection fraction; no HF, no heart failure.
Figure 3
Figure 3
Symptoms measured by NYHA class and reassessment of HFpEF criteria before and after PVI in HFpEF patients. (A) Patients show a significant reduction in heart failure symptoms after PVI. (B) Fifteen out of 35 patients (42.9%) show resolution of criteria for HFpEF diagnosis. HFpEF, heart failure with preserved ejection fraction; no HF, no heart failure; NYHA, New York Heart Association; PVI, pulmonary vein isolation.
Figure 4
Figure 4
Flowchart and results of ablation procedures in HFpEF patients. AT/AF, atrial tachyarrhythmia/atrial fibrillation; HFpEF, heart failure with preserved ejection fraction; rHFpEF, resolved heart failure with preserved ejection fraction; sHFpEF, sustained heart failure with preserved ejection fraction.
Figure 5
Figure 5
Hospitalizations 12 months before the index procedure and 12 months after the last ablation procedure in sustained HFpEF and resolved HFpEF patients. (A) All-cause hospitalization rate (fraction of patients that had been hospitalized at least once) 12 months before and 12 months after the procedure. (B) CV hospitalization rate. (C) Mean all-cause hospitalizations per patient. (D) Mean CV hospitalizations per patient. CV, cardiovascular; HFpEF, heart failure with preserved ejection fraction; PVI, pulmonary vein isolation.
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